Medicare Part B. IMMEDIATE RECOUPMENT REQUEST FORM. To request Immediate Recoupment: 1. Fill out the information requested below 2. Attach a copy of t...
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NOVITAS SOLUTIONS DOCUMENTATION WORKSHEET Medicare Part B Medicare Beneficiary ID Number. Provider Number. Date of Service. Procedure Code Reported. Check one:
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Medicare Part B IMMEDIATE RECOUPMENT REQUEST FORM To request Immediate Recoupment: 1. Fill out the information requested below 2. Attach a copy of the first page of the demand letter 3. Select the option you prefer for this fax 4. Sign and provide contact name and phone number 5. If you are a PA, NJ, MD, DC, or DE provider, fax to: (717) 728-8722 If you are an AR, CO, LA, MS, NM, OK, or TX provider, fax to: (717) 728-8728 This form should be faxed to Novitas Solutions Part B no later than the 16th day from the date of your initial demand letter. NOTE: Providers who request immediate recoupment must realize it is considered a voluntary repayment. Required Information: Provider Name: Provider’s Medicare Number: Provider’s National Provider Identifier (NPI): State Services were Rendered: AL Demand Letter Number(s): Select Option you are requesting in this fax: A one-time request for all invoices included in the current overpayment demand letter(s) listed above and all future overpayments. A request for all invoices in only the current overpayment demand letter(s) listed above. Signature (Provider or CFO): Contact Name: Contact Phone Number: By signing this Immediate Recoupment request, you understand that you are waiving potential receipt of interest payment pursuant to Section 1893(f)(2) for the overpayments. NOTE: Such interest may be payable for certain overpayments reversed at the Administrative Law Judge level (ALJ) or subsequent levels of appeal (935 Overpayments). Visit Medicare Financial Management Manual, Chapter 3, Section 200.1.5 for additional information and instructions for Immediate Recoupment.
